‘The relationship between the person working at the frontline and the individual is all that matters,’ says Martin Nicholas, director of Partners in Support.
Photograph: Getty Images

“Absolutely soul-destroying” is how Cath Loates and Sandra Harris remember the day their home care business was rated inadequate. “It knocked the wind out of my sails, out of all of us,” says Loates, the company director.

After working to establish Eboney Home Care in Consett, County Durham, over seven years, Loates and Harris decided to step back from the day-to-day running and hand over the reins to other staff in 2012. “But actually, we should never have taken our eye off the ball,” says Loates.

A 2015 inspection by the Care Quality Commission (CQC) found an “absence of robust care planning” and that records “were not fit for purpose” or routinely audited. To set things right, Loates and Harris returned to their hands-on roles to overhaul the policies and procedures.

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“As we implemented the changes, we could see what was missing,” says Harris, Eboney’s registered manager. “Although all the care workers work closely with the service users, we still have to hold as much information as we can to do the best for them – and that information just wasn’t there. We had to pull all that back together again.”

Going back to square one paid off. Eboney Home Care was rated good overall following a spot inspection in June 2016, and again in October 2018 – this time with an outstanding rating for caring. Eboney’s care workers are “absolutely over the moon”, says Loates. “They’ve done all the hard work so they’re thrilled to bits that it’s been acknowledged that they’re outstanding. We already knew, but it’s nice to have it written down.”

The majority – 82% – of the 7,191 English home care agencies inspected by the CQC are rated good overall, but just 3% are ranked outstanding.

The bar is deliberately set high, says interim chief inspector Debbie Westhead. “Yes, it’s difficult,” she says. “But with commitment, hard work, creativity and vision, it can be achieved – and it will benefit the people being cared for.”

For the CQC, the benchmark of outstanding domiciliary care is a person-centred service, responsive to the needs and wishes of the people it supports. “It’s treating people as individuals, really getting to know their likes, dislikes and aspirations,” explains Westhead. The regulator also looks for strong links between the care agency and the local community and the use of technology to help people stay active, independent and connected, as well as strong leadership and a culture of openness.

“The issue is that if you want high-level, flexible, personalised care, you need to pay a higher hourly rate and to buy in more time,” says Martin Green, chief executive of Care England, adding that outstanding-rated domiciliary care services “are predominantly ones that are not publicly funded”.

With ever-constrained budgets and more and more people requiring care at home, most councils can only commission the minimum amount of time it takes a care worker to meet the legal definition of personal care, leading to 30-minute drop-ins and, still today, the widely condemned 15-minute flying visits.

Self-funders, however, can decide how much time and money is spent on their care. They can also request care workers’ help with a range of activities beyond simply meeting their physical needs, such as household cleaning or going out for the day. “Providing trips out from home is something you’re very unlikely to get from a state-funded package,” says Colin Angel, policy and campaigns director of the United Kingdom Homecare Association.

Giving clients a sense of wellbeing is key for Carefound Home Care in Wilmslow, Cheshire, one of only 10 domiciliary care services in England rated outstanding in all five areas assessed by the CQC.

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“When we talk about [wellbeing], we don’t just mean doing the basics and, frankly, keeping them alive,” says director Oliver Stirk. “[It’s about] giving them the reason they want to be alive, making sure we’re doing all those things around companionship, interests and activities, and trying to embed that in the people we employ.”

Carefound, which also has an outstanding-rated service in Harrogate, North Yorkshire, hires just 2% of those who apply. “We know what we need in terms of someone’s approach, personality and skillset,” says Stirk.

Recruitment is also integral to the ability of Partners in Support, based in Hertfordshire, to provide outstanding care to adults with disabilities and autism.

“We recruit staff to work for specific clients and the client is involved in the recruitment process,” explains Martin Nicholas, the director of the service, which is also rated outstanding in all five areas. “The relationship between the person working at the frontline and the individual is all that matters. It’s not just about filling a gap.”

Unlike Carefound, the majority of Partner in Support’s clients are state-funded, but the business will decline a care package if it does not feel it is right.

“If we believe someone needs 50 hours of support a week and it’s been offered [by the local authority] at 20 hours a week, and we think that will put [service users] – and our reputation – at risk, we wouldn’t do that service,” says Nicholas. “And we would be very clear why.”

The self-pay market also allows providers to offer specialised staff training, which is rarely commissioned in state-funded care, says Green. “You might get training around lifting and handling but you might not get training around how you deliver personalised care, because there is limited time.”

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All of Carefound’s care workers, for example, have received training in the Specal method by Oxford’s Contented Dementia Trust, as well as from Parkinsons UK and the MND Association. “If a care worker is going in to help someone with a specialist condition, we make sure we’ve actually given them genuine training in it,” says Stirk.

For all care services, it is crucial to demonstrate progression to inspectors – even those already rated outstanding in five areas. Carefound Homecare is taking on the challenge by using data to improve processes and procedures, for example, by revising falls risk assessments.

“We want to make our service more proactive in dealing with risks because, ultimately, that’s where home care can really change someone’s [quality of life],” says Stirk. “If you can prevent them ending up in hospital or residential care, you can make a huge difference to someone’s life.”